I Learned About Medicine From That: the first patient I cared for who died

My new series

I want to start a new series on Sensible Medicine. It’s called: I Learned about Medicine From That; These are first hand accounts since I started in medicine in 2005. This is about the first patient I took care of who died.

-Vinay Prasad

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The University of Chicago still believed in paper charts when I was a third year student on the Medicine clerkship in the summer of 2007. The pavement was scorching, but the air-conditioned halls of the hospital were nearly refrigerated.

My resident had assigned me to JP, a 26 year old man with Lupus. I almost wrote boy instead of man because in many ways he was a boy. He had had lupus since he was a kid — he told me all he ever remembered was being sick — and the steroids he had taken had left him with a small buffalo hump, a soft midsection, and a wide almost baby face.

He was one of the tough patients that residents didn’t care for. He requested narcotics around the clock. Of course, he probably was in some pain, but, probably also, he enjoyed the way it made him feel. Outside of the hospital, his life was a mess. He partied, forgot to take his meds, had no reliable place to stay. He was poor, black, and living on the South Side of Chicago.

Back in those days, I was also a boy. I must have been 23 years old — and I was very emotional. I felt things deeply. I romanticized life, and often would lie in bed and stare at the ceiling just daydreaming.

I haven’t done that in ages, or perhaps I haven’t had the time to. It is hard to know which. The next 10 years of life and training would change that aspect of myself. I do sometimes miss the idealism of youth, the excitement of possibilities, how deeply you can feel things.

JP and I spent a lot of time talking, and I turned these conversations into a shortened, handwritten History and Physical and daily notes and presented it to my attending. My attending would ask me questions about the mechanism of action of the drugs we were giving. Since, I was so close to pharmacology, I remembered precisely. This pleased him immensely. The residents rolled their eyes. They knew much better than me. They knew when to give drugs and how to dose them and when to hold them, and they could care less about the precise place in the signaling cascade that the drug acted.

I felt I knew JP. Of course, I knew nothing about lupus, and wasn’t clear why he was even in the hospital or when he could go, but I knew his voice, the way he would pace the halls. I knew when he was going to ask me if I could send the nurse with his pain medication. I wished him well. I felt strongly that lupus might not be the biggest challenge in his life.

And then, he was discharged. I rotated off service. And a few months later, a surgery resident was showing me a grotesque picture of necrotizing fasciitis, and a body that had been carefully filleted, and I recognized the name on the chart. It was JP. I felt the hairs on my body rise. I wasn’t sure if my voice was shaking. What happened to him? I asked.

I already knew the answer. He had died in the ICU. The resident said it nonchalantly and moved on to the next task. But I didn’t. I was distracted for the rest of the day.

Since I trained in medicine, they have created a huge bureaucracy of wellness officers to help preserve students’ mental health. But I am not sure that despite 10 new titled positions, students have anyone to talk to in these situations. Back then I am sure I didn’t. I talked about it a little with my friends.

Later, I saw the resident who supervised me when we were taking care of JP. I had wanted to see her for some time. She greeted me warmly. How are you? Do you still know all the mechanisms of action, she joked. I asked her if she knew that the patient we shared had died. And he was only 26. Oh yea, she sighed. That was really sad, she patted me on the shoulder. Anyway, it was wonderful seeing you, and let me know if you are going to do medicine. You should consider it. And she was off.

I learned about medicine from that. I learned that something would happen and the tragedies we see would not wear on me so heavily. I knew that I would be less emotional in the years to come. I knew I wouldn’t lie in bed for hours and stare at the ceiling and daydream.

I still think that it was unfair what happened to JP in this life. To be poor and sick, and bitter at your doctors for not giving you more narcotics. Sometimes I wonder what would happen if we just let patients who often get narcotics — the chronically ill, those with sickle cell disease — have total control over their own pain medication. The doctor only advising them to take it easy, but not stopping it. Perhaps it could even be studied against the status quo. Now I know just how little we know about treating people in chronic pain.

But back then I was sure of only a few things. I knew JP wanted to increase his dose of narcotics. I knew my attending was really interested in mechanisms of action of medications. And I knew the road I was on was going to make me a different person.